Colorectal cancer: summary of NICE guidanceBMJ 2020; 368 doi: https://doi.org/10.1136/bmj.m461 (Published 02 March 2020) Cite this as: BMJ 2020;368:m461
All rapid responses
We read with interest the review of the NICE guidelines on the management of colorectal cancer (BMJ 7th March 2020). In the section on treatment of colorectal pulmonary metastatic disease, the article is misleading. All cardiothoracic surgical units in the UK regularly undertake pulmonary metastatectomy for colorectal carcinoma. Certainly in our unit and probably in all other UK cardiothoracic units colorectal carcinoma is the commonest reason for carrying out pulmonary metastatectomy. In our experience the 5 year survival following potentially curative pulmonary metastatectomy is at least 50% whereas patients managed with chemotherapy have a 5 year survival of around 5%. This may change in future with the introduction of new biological agents for the treatment of colorectal cancer but we feel it is only fair to point out to the BMJ readership that pulmonary metastatectomy by means of lung resection is commonly carried out in the UK and has excellent results in appropriately selected patients.
Competing interests: No competing interests
In the summary of NICE guidance on the management of colorectal cancer (1) there is a recommendation that ‘people with lung metastases suitable for local treatment’ should be considered for ‘metastasectomy, ablation, or stereotactic body radiation’. Although this is a ‘weak’ recommendation, it will increase the already widespread use of these interventions.
The PulMiCC randomised trial which tested the value of pulmonary metastasectomy in colorectal cancer has been published and shows no significant overall survival advantage from intervention (HR 0.82 (95%CI 0.43, 1.56)) (2). Importantly it also showed that the 5-year survival in the well-matched control group, none of whom had metastasectomy, was 29%, far higher than the generally assumed and widely quoted figure of worse than 5%.(3)
The only evidence supporting the NICE recommendation was a retrospective observational study(4) in which control patients had a number of significantly worse prognostic factors and none survived to 5 years. This study was considered at ‘serious’ risk of bias and of ‘very low’ quality by the NICE systematic reviewers - poor evidence on which to base a recommendation which will expose many patients to significant risk of harm. The only randomised trial evidence(2) does not show any benefit from metastasectomy and clearly undermines the general assumption that without intervention few patients survive to 5 years.
NICE should reconsider this recommendation urgently in the light of this and other relevant but more indirect evidence. The NHS should not waste resources on ineffective or unvalidated procedures.
(1) Bromham N, Kallioinen M, Hoskin P, Davies RJ. Colorectal cancer: summary of NICE guidance. BMJ 2020; 368:m461.
(2) Treasure T, Farewell V, Macbeth F, Monson K, Williams NR, Brew-Graves C et al. Pulmonary Metastasectomy versus Continued Active Monitoring in Colorectal Cancer (PulMiCC): a multicentre randomised clinical trial. Trials 2019; 20(1):718.
(3) Gonzalez M, Poncet A, Combescure C, Robert J, Ris HB, Gervaz P. Risk factors for survival after lung metastasectomy in colorectal cancer patients: a systematic review and meta-analysis. Ann Surg Oncol 2013; 20(2):572-579.
(4) Kim CH, Huh JW, Kim HJ, Lim SW, Song SY, Kim HR et al. Factors influencing oncological outcomes in patients who develop pulmonary metastases after curative resection of colorectal cancer. Dis Colon Rectum 2012; 55(4):459-464.
Competing interests: Tom Treasure is the Chief Investigator and Fergus Macbeth is a member of the Trial Committee of the PulMiCC trial